{"id":40100,"date":"2020-02-13T16:03:41","date_gmt":"2020-02-13T21:03:41","guid":{"rendered":"https:\/\/www.med.unc.edu\/medicine\/?p=40100"},"modified":"2023-06-06T17:50:42","modified_gmt":"2023-06-06T21:50:42","slug":"deprescribing-in-older-adults-an-interview-with-josh-niznik-pharmd-phd","status":"publish","type":"post","link":"https:\/\/www.med.unc.edu\/medicine\/news\/deprescribing-in-older-adults-an-interview-with-josh-niznik-pharmd-phd\/","title":{"rendered":"Deprescribing in Older Adults: an Interview with Josh Niznik, PharmD, PhD"},"content":{"rendered":"

Josh Niznik, PharmD, PhD, Assistant Professor, Division of Geriatric Medicine and Division of Pharmaceutical Outcomes and Policy at the Eshelman School of Pharmacy, is a geriatric health services researcher with clinical training in the pharmaceutical sciences. His research is focused on evaluating the quality of medications in older adults to improve the safety of medication use in this population.<\/p>\n

\"Josh<\/a>Most recently his work has focused on evaluating the impact of deprescribing or discontinuing chronic medications that may no longer have value in nursing home residents with severe dementia.<\/p>\n

Do you think that older adults have high rates of medication burden?<\/strong><\/p>\n

Of course \u2013 and to the point where it\u2019s very problematic. More than half of older adults are exposed to polypharmacy and the unfortunate thing is that those people are more susceptible to side effects and they\u2019re more vulnerable to drug-drug interactions. In a report by the Lown Institute, medication overload has been called \u2018America\u2019s other drug problem.\u2019<\/p>\n

There are many opportunities to re-evaluate the appropriateness of a lot of medications particularly in the work that I do with deprescribing. We could do a much better job talking with patients and families about things like time until benefits and how long benefits actually persist for. When we think about the scale of harms and benefits, at what point are we not doing what we set out to do, which is to prevent complications from disease rather than causing unintended consequences of medication exposure\u2026?<\/p>\n

What\u2019s \u2018time until benefit\u2019? <\/strong><\/p>\n

\u2018Time until benefit\u2019 is how long someone needs to take a medication at the recommended dose until they would see the intended benefit of the medication. For instance in osteoporosis medications, to see reduced risk of fractures, a patient would essentially have to be on those medications at least a year to see that benefit. For someone who maybe has a limited life expectancy, we need to be very clear about what we\u2019re doing so that we\u2019re not putting people on medications unnecessarily \u2013 and wasting money.<\/p>\n

How many medications equate to \u2018polypharmacy\u2019? <\/strong><\/p>\n

There are varying definitions of polypharmacy but I tend to say 5 or more. A lot of older adults are on 10 or more medications. In nursing homes at least half of residents are on10, with the mean number being closer to 15.<\/p>\n

When did you realize that de-prescribing would be your key area of focus? <\/strong><\/p>\n

I didn\u2019t really decide on this direction until I was in graduate school and started doing research more seriously. I did a few rotations my last year of pharmacy school where I saw a lot of older patients. This highlighted the opportunity that pharmacists have to optimize medication use for these patients, particularly when you\u2019re thinking about whether a medication is causing a side effect. In a lot of cases, a specific medication actually is what\u2019s causing the problem.<\/p>\n

Providers are generally trained when we see problems to think about medications can be used to treat it. We don\u2019t often think of the reverse: \u2018this is the problem \u2013 what medication is causing it?\u2019 For a lot of older adults, the medication is causing a problem or side effect.<\/p>\n

My grandmother had Alzheimer\u2019s disease and end-stage renal disease. She was on a list of more than 10 medications. Her dementia progressed to the point where she couldn\u2019t ambulate for herself or really have any activities of daily living (ADLs). Yet many of her medications were preventive \u2013 things like anti-dementia and osteoporosis medications which were very unlikely to be providing any benefit at that point.<\/p>\n

I think that she really could have benefitted from deprescribing some of her medications particularly at the later stages. It was eye-opening and has served as one of the drivers of why I\u2019m very passionate about this. It\u2019s important for physicians, patients, and caregivers to realistically discuss the benefits a medication can and can\u2019t provide, and to have a plan for de-escalating or stopping certain medications.<\/p>\n

Tell us about your recently published paper in Journal of American Geriatrics (JAGS). \u00a0<\/strong><\/p>\n

This study<\/a> on the \u201cRisk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents with Severe Dementia\u201d has gotten a lot of attention, I think because there\u2019s a growing consensus that anti-dementia medications are not that useful. They have lots of side effects, some with 2 to 5 times more risk of side effects compared with patients who aren\u2019t on them.<\/p>\n

\"anticholinesterase<\/a>For managing dementia, particularly in the later stages, we\u2019re thinking about comfort and palliative goals of care. Yet the side effect of anti-dementia medications are directly in conflict with those goals of care: GI issues, headaches, and weight loss and more. The potential for benefit with these meds is very modest, and these are all side effects that negatively impact quality of life. Any evidence to justify stopping them is really what we need, and this paper presents that evidence.<\/p>\n

Is there any benefit to using anti-dementia medications? <\/strong><\/p>\n

In some cases there is modest benefit, but prescribing appropriately requires a patient-centered approach. Different interpretations of the evidence about use \u2013 and the evidence can at times seem mixed \u2013 can lead to clinicians and families deciding to \u2018give it a try\u2019 with a certain medication. My counter argument to the \u2018give is a try\u2019 approach is be sure you\u2019re thinking adequately about quality of life.<\/p>\n

If you\u2019re taking that approach, begin by setting reasonable expectations for what to expect. Have a plan to monitor whether medications are working and a plan for knowing when to stop.<\/p>\n

 <\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

“More than half of older adults are exposed to polypharmacy and the unfortunate thing is that those people are more susceptible to side effects and they\u2019re more vulnerable to drug-drug interactions. It\u2019s important for physicians, patients, and caregivers to realistically discuss the benefits a medication can and can\u2019t provide, and to have a plan for de-escalating or stopping certain medications.”<\/p>\n","protected":false},"author":31116,"featured_media":40102,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"layout":"","cellInformation":"","apiCallInformation":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[99],"tags":[629],"class_list":["post-40100","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-geriatric-medicine","tag-629","odd"],"acf":[],"yoast_head":"\nDeprescribing in Older Adults: an Interview with Josh Niznik, PharmD, PhD | Department of Medicine<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.med.unc.edu\/medicine\/news\/deprescribing-in-older-adults-an-interview-with-josh-niznik-pharmd-phd\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Deprescribing in Older Adults: an Interview with Josh Niznik, PharmD, PhD | Department of Medicine\" \/>\n<meta property=\"og:description\" content=\""More than half of older adults are exposed to polypharmacy and the unfortunate thing is that those people are more susceptible to side effects and they\u2019re more vulnerable to drug-drug interactions. 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